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stop the war on the emergency room (fix the system failure)

There’s a war being waged on one of America’s most revered institutions, the Emergency Room. The ER, or Emergency Department (ED for the sake of this post) has been the subject of at least a dozen primetime TV shows. What’s not to love about a place where both Doogie Houser and George Clooney worked?

Every new parent in the world knows three different ways to get to the closest ED. It’s the place we all know we can go, no matter what, when we are feeling our worst. And yet, we’re not supposed to go there. Unless we are. But you know, don’t really go.

Somehow, we’ve turned the ED into this sacrosanct place where arriving by ambulance is ok, and all others are deemed worthy based on their insurance rather than acuity. If you think I’m wrong, ask any ED director if they want to lose 25% of their Blue Cross Blue Shield volume.

But its true. I hear ED physicians openly express disappointment in people who came into the ED and shouldn’t have. It’s just a stomach bug, you shouldn’t be here for this… Or, it’s not my job to fill your prescriptions…

Today, NPR’s Julie Rovner published a synopsis of recent findings from Oregon’s Medicaid expansion and its effect on ED use:

“Medicaid coverage increases emergency department use, both overall and for a broad range of types of visits, conditions, and subpopulations,” says Amy Finkelstein, an economics professor at MIT and one of the authors of the study. “Including visits for conditions that may be most readily treatable in primary care settings.”

“When you make ER care free to people, they consume more of it. They consume 40 percent more of it,” says Michael Cannon, head of health policy for the libertarian Cato Institute. “Even as they’re consuming more preventive care. And so one of the main arguments for how Obamacare was going to reduce health care costs is just flat out false.”

Some history

The Emergency Department is a fairly modern invention. The first EDs were born of two separate, though similar, aims. At Johns Hopkins, the ED began as the accident room, place where physicians could assess and treat —wait for it —minor accidents.

Elsewhere, in Pontiac Michigan and Northern Virginia early EDs were modeled after army M.A.S.H. field hospitals. They were serving more acute needs.

Today, billing for emergency department visits is done on the E&M Levels where level 1 is the least acute (think removing a splinter) and level 6 is traumatic life saving measures requiring hospitalization (think very bad car wreck). Most EDs, and CMS auditors, look for a bell curve distribution, which means there are more level 3 and 4 incidents than most others. While coding is unfortunately subjective, solid examples of level 3 visits include stomach bugs requiring IV fluids, a cut requiring stitches, and treatment of a migraine headache.

What’s my point?

  • Most EDs treat minor needs.
  • There is historical precedent for treating minor needs (accidents).
  • Over use is a concocted problem resulting from a red herring of cost and thinly veiled desire to keep lower paying plans and less compliant patients out of the high profit ED.

There, I said it.

What the Oregon study tells me is that the ED represents a clear desire path for consumers. Healthcare economist Austin Frakt put it well in his reaction:

Ultimately, my view is that “overuse” of the ED reflects the broader problem that the health system is not very responsive to consumer demand or sensitive to all types of consumers. (The disparities literature is relevant here.) In other words, it’s not consumers making “bad” choices, but the system offering poor ones.

The ED is convenient, it’s open 24 hours, it does not require an appointment. So when the stomach bug or kitchen accident gets the best of you at 9:00 PM, and your doctor’s office is closed, where are you going to go? And, yet, we still chide people —via reporting, casual comments and the communication of health systems —for using the ED for “non-emergent” needs.

Who determines what is emergent? But I digress…

What I’d like to see is more hospitals flinging open the doors of their EDs and saying, *we’ll take you, any time, for any reason, and you won’t wait long or pay an arm and a leg…"

Sure, we need to acknowledge that the ED is probably not the best place for primary care. But, whats a body supposed to do when their primary care office has a 3 day wait and is closed at 9 PM? Tackle that system problem, and I’ll sing a different tune.

A few years ago, while working for a large hospital, I was part of a team exploring an expansion into urgent care. Urgent care, as the name implies, is like emergency care, only…you know…less emergent and more urgent. We wanted to offload some of the lower acuity visits from the ED, but didn’t want to lose the volume. Urgent care made sense. So where do we put it? Well, on the campus of the hospital was ideal, it had the benefit of being able to turf people out one door, across the parking lot and into the urgent care. But that required new or repurposed space, which is expensive.

What, in fact, made the most sense was to make the urgent care part of the ED itself. In other words, have a bargain sale isle in the ED. You do that by staffing differently, ordering fewer tests, and generally charging less. Which is where the conversations ended.

But, I still think that’s a viable solution. Rather than continuing to wage war on the poor ED, we need to build EDs which are capable and cost effective at caring for every need which walks in the door. That includes being timely, compassionate, participatory, and affordable. It requires being connected via EMR to primary care offices. And, above all, it means listening to the desires of communities who have a need for the 24-hour, walk in care option.

Are health start-ups creating cooler cultures than the hospitals they serve?

I’ve written before about my concerns about work environment in many hospitals. I looked at culture when applauding Evernote’s employe-centric policies and again recently when exploring the Bossless Office. Writing for the Washington Post’s Wonk Blog, Sarah Kliff looks at the trend of hospitals forming their own insurance plans. Us healthcare nerds call these risk-bearing entities, and it’s not a particularly new idea. Why be beholden to a third-party insurance company if you could cut them, and the associated overhead, out? That’s been a key component of Geisinger’s Proven Care program for years.

When I speak to hospital administrators about innovation, what I often hear about is new, experimental models for paying for healthcare.

I’m not sure that’s what the rest of the world thinks of when they hear the world innovation. I think many picture iPhones, Virgin America planes and Tesla sports cars. And when we think about those things, we imagine fun people in jeans gathered in glass-walled rooms imagineering (whatever that means).

What caught my eye in Kilff’s article was her descriptions of the third party company, Evolent, which helps large health systems set up their payor plans.

From the article:

… Evolent Health could be a movie set for a Silicon Valley start-up — the kind that starts with millions in venture capital funding, not in a founder’s grungy garage. An immaculate micro-kitchen, stocked with sodas and fruit, opens to a lounge with a plush white couch and big-screen TV. Two treadmill desks nearby are decked out with laptop workstations. [On a Wednesday morning, though, no employees were using any of these amenities. …[employes] were working, many with headphones on, at long rows of gleaming metal desks. Evolent has no offices, not even for its top executives. Glass conference-room walls are covered in scribbles from red, blue and green markers. “We wanted a sort of Steve Jobs feel,” Evolent co-founder and president Seth Blackley said, explaining the open landscape.

I’m admittedly mixed about what I see as a trend: the innovative, cool places to work aren’t hospitals but rather the companies who support them. On one hand, its nice to know there are places in healthcare to attract a workforce of engaged, creative and modern workers. On the other, will hospitals be left in the dust by millennials and others who desire a less conservative environment?

its not fair to expect a 60 year-old building to look like the inside of an Apple store. Really, space is really a proxy for the culture and nature of work in a given space. Inherent in my thinking is the idea that workplace culture, employee talent mix and innovative strategies are all tied together. I certainly don’t mean to suggest treadmill desks alone will produce the hospital equivalent of Virgin America planes. But is it reasonable to connect environment to talent attraction and thinking?

CancerGeek points out, on twitter, some hospitals do offer modern work environments. But its still pretty limited.

Will more join the fold, or will we see a brain-drain towards smaller, start-up style third-party players?


Here’s the original tweet from TEDMED to Kliff’s article:


Finding & Protecting Time for Patient Engagement

If I have a healthcare-related resolution for 2013, its to be a champion and protector of empathy. As a member of the leadership team of a health system, that means making room for empathy in how we deliver care. Or, put more simply, valuing the time our providers spend with patients over raw productivity or efficiency metrics. As a blowhard healthcare blogger, it means advancing the cause to anyone else who is able to make room for empathy in patient care. Unfortunatly, while we often pay lip service to patient engagement, we usually measure and pay providers on exactly the opposite. Patient-centered communication rockstar Steve Wilkins wrote a great piece on his blog this week: The 10 Commandments of Patient Engagement. In the post, Steve lists 10 actionable steps providers can take to more meaningfully engage with patients during a visit. I agree with every single one of them.

I’m willing to bet most providers - nurses, mid-levels and physicians - would all say the things on Steve’s Top 10 List are things they do, or want to do. Then they’ll sigh and say something like: “but there’s now way we can be expected to strike up a conversation just for kicks, not with the productivity standards we are held to.” If they are self-employed, the later part of that dismay might instead be: “and still pay my bills on today’s lousy reimbursement.”

That’s where I see a very important role for leaders in healthcare organizations - making room for empathy.

Doctors are, generally, paid on a productivity basis. This usually comes in the form of a base salary plus a portion based on something called a worked relative value unit, or WRVU (often called an RVU too). Suffice it to say, it means the more cases a provider sees, or the more complex the case they see are, the more they get paid. Nurses, mid-levels and physicians are all, with increasing frequency, being held to productivity standards. Productivity is often is expressed simply, usually as a number of patients per day. If, on average, a primary care doctor can see patients in 10 minutes, and they have 6 hours of patient time allotted on their schedules per day, that means to be 100% productive they need to see 36 patients per day.

Now, most of us can recognize that’s a pretty lofty goal and one which doesn’t leave much room for longer, more complex patients. It certainly leaves very little room for meaningful interactions. And, even in a more relaxed model of say 20 patients per day, explains why doctors are so often running behind schedule.

The problem for us administrative types is that 20 patients per day looks pretty good on a spreadsheet. And, there are a lot of sources and third parties to back up high efficiency models of productivity. So we push for it. We write productivity goals into contracts, we push nurses to work faster, and we take away any time for empathetic patient relationships.

Then we try and shoehorn empathy in. We coach staff on smiling and key phrases. “Is there anything else I can do for you?” We say we value and even demand the kinds of things Steve Wilkins is asking of providers. But, in reality, we are grading and paying providers on exactly the opposite.

Here’s another example, this time pertaining to nursing. Many of Steve’s commandments are often part of the nursing intake function. So, the graphic below depicts a very simplified flow map of a nursing intake procedure:

In the image above, each step of the process is shown along with it’s approximate time. Some steps, such as listening to the chief complaint may take anywhere from 1–3 minutes. If you add up all the minimal times, this flow takes 8 & 1/2 minutes. If the steps take their maximum amount of time, the process takes over 15 minutes.

If a nurse is being held to a productivity measure which requires they complete this process in the minimum time, what gets cut? Regrettably, all too often, its the part of the process we as patients would say is the most critical - the human interaction.

So, when I write about making room for empathy, I believe we have to look carefully at two key things: our metrics and processes. In terms of metrics, we have to ask ourselves: are the goals we hold staff to consistent with what we are asking of them? In other words, does it work to script customer service phrases while paying bonuses based on productivity? We have to look at processes to see where we can make time.

I understand the need to do more with less, and to better use our resources. But patients are increasingly voting with their feet. If we want to remain viable, we have to make patient engagement a top priority. That means making room for engagment in the patient process flow.

The best way to make room for empathy is to find steps which do not add value. For instance, in the flow image above, would it make more sense for someone else to pull the chart, take the height and weight and room the patient? If we took 3 minutes out of the nursing flow, but kept the expectation at an 8–15 minute process, then we’ve added 3 minutes of face time. It doesn’t sound like much, but we know from studies as little as one extra minute of meaningful, heartfelt interaction can make a huge difference in a patient’s relationship with their provider. By the way, this same process map / time protecting idea works for physicians.

As we head in to 2013, here are my challenges to fellow leaders, administrators and health system executives:

  • Make a PDF of Steve’s 10 Commandments
  • Map out your current patient process flow, record times for each step, average them together
  • Use a LEAN process flow calculator or your own best judgement to find steps which don’t add value to the critical path. This isn’t as tricky as it sounds, it means looking at each step and asking could I cut this out or find someone else to do it and, in doing so, make room for empathy?
  • Remove the steps which don’t add value, or find someone else to do them. Yep, that may mean a hire, but cost today is better than a loss due to poor patient satisfaction. But I think most of us will find there is enough waste in our flows to more than allow for patient engagement.
  • Implement one of Steve’s commandments for everything you cut out
  • Measure marketshare, patient satisfaction and, I argue most importantly, staff satisfaction - all will improve.

From Elsewhere: Lean Blog Podcast & Making room for Empathy

One of my favorite phrases is making room for empathy. Room for empathy is about giving staff the time in their workflows to be compassionate and to deliver care which is not only clinically competent but emotionally uplifting as well. But that’s hard to do.

It’s hard because the work of providing care is increasingly complex. We’ve got EMRs with screens of data. We’ve got sign off sheets, time outs, forms, papers, phone calls, results, and, frankly, CYA work. Those things take time. So what get’s cut? Empathy. We cut out the simple things like walking someone to their destination rather than pointing. We cut out sitting with someone who looks concerned (so we look at our shoes or iPhones in the hallway). It’s a problem

There are two main ways to make more room for empathy. First, we could hire more staff. More staff (nurses, care givers, techs, managers, administrators even) mean more bandwidth. Many hands make light work. But we probably aren’t going to get more staff. Reimbursement is dropping, and there is a push to be more efficient. Hospitals are trying to see if they could survive on Medicare reimbursement rates. (Remember, Medicare pays, on average, about 80% of what treatment costs, so we have to cut about 20% of cost out of hospitals).

The other way we can make room is by eliminating work which does not add value. Productivity gurus say we should work smarter, not harder. I’m increasingly interested in the Lean methodology as a framework for evaluating how we do our work and determining if it adds value, or simply takes up valuable time. So, I’ve been trying to learn more about Lean.

I found Mark Graban’s Lean Blog which led me to his Lean Blog Podcast, a regular, downloadable audio show about Lean. In the most recent episode, Dr. John Toussaint of ThedaCare, discusses the importance Lean methodologies in healthcare.

It’s a fantastic listen and should inspire anyone looking for ways to make room for empathy and return the focus to patient and staff experience.

For some healthcare players, innovation is already a priority

Lately, I’ve been writing about innovation and design thinking in healthcare. I often make general observations about the industry like innovation is rare in the delivery of care or we need to learn how to use design thinking. While they may be present as buzz words, largely I stand by the assertion that they are rarely deeply integrated into the culture of most health systems. But there are some standout exceptions and I’d be remiss if I didn’t highlight the places where innovation is part of the culture.

  • Kaiser’s Garfield Center for Innovation - Kaiser’s center was among the first of its kind in healthcare. The Garfield center was established out of work the health system did in collaboration with IDEO. A team of clinicians was tasked with redesigning nursing units and the processes around them. On the heels of a successful redesign, the team formed the center to become a source of new ideas for the system as well as internal consultants. Kaiser’s innovation center is profiled in Tim Brown’s Harvard Business Review case study on Design Thinking.
  • Mayo Clinic Center of Innovation - Mayo’s center builds on the Mayo brother’s early idea of patient-centered care. The Center occupies a large glass workspace in the lobby of Mayo’s Rochester location, giving it both prominence and literal transparency.
  • United Healthcare’s Innovation Team - United is a large commercial payor with roots in the provider world. United has a VP of Innovation who, along with his team, is responsible for promoting design thinking across the organization. United has also started offering innovation consulting to providers through its process improvement program.

This is by no means an exhaustive list. You can probably name some other health systems or industry players with innovation and design teams. We have a ways to go before empathetic design becomes widely adopted in the industry. But it is important recognize that innovation is already a priority in some organizations.

Want to build the health delivery system of the future? Just think like Mick Jagger.

This post orignally appeared on the Stanford Medicine X blog, you can find it in it's entirety there. 

Pick a classic rock band. Go ahead, I’ll wait. You’re thinking of The Rolling Stones aren’t you? No? Well you are now. When we think about band like the Stones, we often describe them as iconic. The Stones had a unique sound, didn’t they? Seeing them live was a unique experience (or so I’m told). The reality is The Rolling Stones were total copycats.

So why do we love watching Mick strut back and forth singing Honky Tonk Woman? Innovation!

Want to read more? Check out the full post on the Stanford Medicine X blog.

Quite shy, Keith Richards spent his formative years alone, listening to and mimicking American blues and jazz artists. Richards was enamored with Chicago blues artists like Muddy Waters (who later become an icon of delta blues). He also had a fondness for rock-n-roll star Chuck Berry. He spotted a guy toting American blues records under his arm, while walking between classes in college, and recognized him as an estranged primary school classmate, Mick Jagger. The two, along with a crew of supporting characters, began booking gigs based on their reputation for covering American R&B tunes. [1]

When they began to pen original tunes, two of their bandmates quit, in protest over the duo's love for Chuck Berry's style. Undaunted, Jagger and Richards focused on incorporating Berry's love of casual guitar riffs and Chicago blues-style lyrics into everything they wrote. Today, when we listen to classic, defining tunes like Give Me Shelter, what we are really hearing is innovation. [2]

Jagger and Richards took something existing and built on it to create something new. And that's what innovation is.

Innovation is about seeing trends and ideas in other spaces and applying your expertise and creativity to them to iterate and create something new. It is a skill which can be learned and cultivated.

Oddly, we rarely see innovation in the process of delivering care. Certainly, there have been advances in medicine, techniques and devices, yet largely the delivery process has remained unchanged. Perhaps that's because it is easy to confuse innovation with invention. Totally new ideas, the kind which come out of the blue, are lightening strikes compared to the frequent, iterative nature of innovation. For that reason, it is much easier to practice innovation than many suspect. Don't believe me?

Think of an iconic 21st century consumer electronics design. Go ahead, I'll wait. You're thinking of the iPod aren't you? Darn it! Well, you are now. You're imagining the simple, white, elegant design; totally new, totally unlike other MP3 players with their ugly buttons and clunky shapes. Right?

T3 Pocket transistor radio | Dieter Rams | Braun

See the resemblance to Dieter Ram's design for Braun's T3 1960's transistor radio? Here is the essence of innovation. Just like Richards, inspired to noodle bluesy riffs by Chuck Berry, created something iterative and new, Apple's Jony Ive looked at an elegantly designed radio and thought how does this inspire us? Shameless? Hardly. Steve Jobs often quoted Pablo Picasso, "bad artists copy. Great artists steal."

Stanford's MedX is all about taking a queue from Richards and Apple. Innovation is easy, but it does require practice. Stanford's MedX conference has an emphasis on inspiring innovation thinking. Michael Graves, renowned architect and designer, will headline the event, discussing his experience as a patient. Graves is outspoken about the need for innovation thinking in delivery of care. Beyond Graves, the entire event will use innovation as a theme to inspire the next iterations on care delivery.

Want to get started practicing innovation? Here's a simple example:

Think about a company that revolutionized a drink commodity into a retail and lifestyle juggernaut in the last 20 years. Really, I don't mind waiting. You're thinking of Starbucks aren't you? I knew it! We're together on this, you and me. What are some attributes of the Starbucks model?

• Inviting spaces - ever notice how Starbucks' shops have big, over-sized, comfy furniture as well as hard surfaces? Sometimes we want to sit and chat. Other times, we need to get work done. • Rent-a-space - Ever thought of a Starbucks as your out-of-town office when traveling? Wifi, power, a desk…it's perfect. That cup of coffee you bought effectively paid your rent on the space. • Adopt-a-style - Like the Starbucks experience? Why not buy a porcelain mug designed after their paper coffee cup? You can also pick up cards with iTunes links to the mellow coffee house vibes they play. Grab a bag of beans and you are on your way to recreating the baristia experience at home. Cha-ching!

Now, think about the process of delivering health care. See any similarities? It's ok if they don't jump off the screen. But really think about it. Channel your inner Mick Jagger. What can Starbucks inspire about how we deliver care? Is it a retail model, or branding effort, or customer experience design? What about a new layout for a clinic, or walk in model? I don't know, but I bet you can pull an Apple and build on Starbucks' ideas to create something entirely new.

Innovation doesn't mean creating a new idea from scratch. Rather, innovation is a learnable skill which is all about observing existing trends, ideas, processes and technologies and applying your own iteration on them to create something entirely new. After all, remember what the artist Bansky said:

Banksy v Picasso Bad artists imitate Great artists steal

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Milk's Oink - a model for rapid development in healthcare

Last week, tech startup Milk, inc shuttered its first and only app, Oink. Stop laughing. Those are the real names. Ok, only in the tech world, right? Jokes aside, deciding to pull the plug on a major project is not easy. Kevin Rose, Milk's founder, and the team have stated they are committed to rapid, agile development. It's an idea we could learn from in healthcare.

The company’s explanation was: “We started Milk Inc. (the company behind Oink) to rapidly build and test out new ideas. Oink was our first test and, in preparing to move onto the next project, we’ve decided to shut it down to help focus our efforts.” - via All Things D

Easy to say, hard to do

The trend of rapid development is gaining traction in tech startups. The basic idea is to continually innovate on products and services - they may never reach a finished state. In some instances, like Milk's, the products may yeild some success, but fail to fully meet expectations. In that case, developers look at lessons learned from the project and move the successful parts into new projects, leaving the failed peices on the cutting room floor. Continue what works, abandon what doesnt.

If the idea of abandoning projects mid-stream sounds challenging, it is. Teams have to ask themselves many questions such as when is the right time to pull the plug? How do we define success vs failure? What are the parts to keep and what should we leave behind? Perhaps that's why tech pundants have lauded Rose and team for their decision to stop Oinc.

Hey, clearly it worked out for them:

Google today confirmed the news we brought you yesterday: Kevin Rose and some of the team from his mobile app incubator Milk will be joining the company. - Via All Things D

Like most established industries, healthcare is steeped in tradition. One of the challenges of our tradition is a cautious approach to change. Largely, and justifibly, that's because rapid change in the practice of medicine has high risks, and we don't want to take risks with peoples lives. But there are some places within healthcare where rapid develipment and risk taking makes sense.

The professional side of healthcare - administration, business development, IT, marketing, management, etc - has historically taken clues from the medical tradition: slow, calculated decisions based on evidence, research, detailed financial plans, etc.

In adopting a rapid development model, professional teams could reduce some of the ramp up time for projects by getting comfortable with failure and change. Not every idea is a home run, sometimes it's just about getting on base. If the idea has some merit, take the positives and apply them to the next iteration.

Practicing rapid development

In the last few weeks, I've had an opportunity to explore rapid development. A team approached me with a clever idea. (It really doesn't matter what team or what their was. Names have been changed to protect the innocent, you get it.) As the innovation guy, it's my job to help them incubate and pilot the idea. So we tried it.

A few days in to the pilot, we hit snags. Part of the process stalled, dependant on another team and other processess. Pretty soon we had a massive reply-all thread going on email and enough differing opinions to make Congress jealous. (I'm here all night, tip your waitress, try the veal).

We were at a crossroads - stall the project, build a larger team and try and compermise on the orignal idea, or rapidly develop the idea into something else. We chose the later.

We did a quick assessment of the orignal idea and looked at the parts we felt worked well. We then discontinued the pilot in its current form. We let the other participants know and told them why and what our next steps were. Right away, we started a new pilot, plan b. Since we had building blocks from the successful parts of the first pilot, we were able to drop those processess and tools into place right away. We again communicated with the larger team.

To pharaphrase: "Hey, were't not perfect, but with your help and support we'll continue to refine this process. Thanks for your patience. Instead of A B and C, would you please start using X Y and Z?"

So far, the team has gone along with us. We understand they will eventually reach a point of change fatigue. To mitigate that risk, we know we cannot be in a state of rapid development forever. However, if we can use the tactic to keep the important parts of the orignal idea moving while we develop a stable process, then it will be a success overall.

What about you - have you practiced some sort of rapid development in healthcare? What are your tips and lessons learned? How have you learned to accept partial success along with partial failure? Does rapid development differ from basic project management skills?

Designing for happiness

I have the privledge of conduting new employee orentation for my health system. There is an excersize I ask the new hires to go through which I’ll share with you here.

Take a few moments and think about something in your life you cannot imagine being without….something where you think I don’t remember how I got along without XYZ… It can be a thing, or a place, or even a person.

What did you think of?

9 out of 10 new hires usually shout out “my iPhone”.

Sure, some folks reply with non-consumer answers such as my family, my children, or my last vacation. But for the ones who say it is their phone, what makes it such a compelling device, why could they not live without it? What they often tell me is it’s just magic, it just works. Apple’s marketing department would be happy with that response. I believe its just magical is a proxy for it was designed well.

Over the weekend I had the chance to re-watch one of my favorite documentaries, Objectified. Objectified is director Gary Hustwit’s homage to industral design and designers. The film moves from vignettes of iconic design to narritaves of personal insight from famous designers. It is a wonderful film and part of a trillogy where Hustwit focuses on asthetics and design.

In healthcare, we often think about design in a few very narrow contexts. We think about the archatecture of new buildings. Sometimes we think about the shape and styling of medical devices. Yet, that’s not how designers see the world. As Jony Ive, head of design for Apple, puts it: “it’s part of the curse of what we do… think about how everything we encounter is designed.”

In Objectified, Erwan Bouroullec, of the designers says the goal of design about creating an enviroment where people feel good.

Isn’t that sort of also the goal of a hospital or doctor’s clinic? Don’t doctors start practing medicine because it feels good to take care of people? Don’t we go to the doctor because we want to feel good?

Regrettably, so many of our processess for delivering care were designed by consensus, rather than with a goal of creating an eivnroment where people feel good.

A few months ago I wrote a post about designing for experience where I suggested many processess are designed by consensus, or created through committees which often involve compromise for political agreement or to avoid conflict.

Try my new hire exercise again only this time think about an object or process which makes you feel frustrated or challenged when you interact with it.

My guess is whatever that thing is, it was probably not well-designed. It may be the result of design through consensus or it may simply not have been designed with attention to user experience or detail.

Now, more than ever healthcare needs to begin to apply design thinking to its processes and services. Design thinking has two major benefits: first it builds things which are in empathetic towards the user. Secondly, as Bouroullec says, it makes people feel good.

Davin Stowell, a principal designer at SmartDesign discussess working with OXO, the kitchenwares company on their vegitable peeler. Stowell says it’s not as important to understand how the average person who use the vegetable peeler. What matters is the extreme usecase - the person with arthirtis in his example. “When you design for extremes, the middle takes care of itself…” says Dan Formosa, also of SmartDesign.

Healthcare has an opportunity to embrace its extreme users too.

Examples most certinally include those who identify as ePatients. ePatients want to participate in the development and implementation of their treatment plans. They often lament a lack of access to their clinical data, or even access to their physicans using modern things like text messaging or skype.

We might also look at other extemes for inspiration. What can a “frequent flier” in the ER tell us about processess in the emergency room? What can the single, working mother with three kids tell us about process in the familiy medicine clinic?

These users are all around us, yet for some reason, we fail to consider them when designing care delivery processess and services. Instead, we design for the middle, creating average offerings rather than standout offerings.

There are competitive advantages to good design. It gets more people in the door. There are also imporant humanistic aspects. If good design really does create an enviroment that makes us happy, doesn’t healthcare have an obligation to design things well?

It is not my intent to judge our entire industry unfavorably. Good design can be as ambigious as the term itself. If it were easy, every phone manufactureer would have invented the iPhone years ago, right?

Still, there are ways to learn and practice design thinking:

  • Watch Objectified - pretty good place to start. It’s on Netflix for streaming. Listen to the designers talk about the objects they’ve designed and apply their terms and language to processess and experiences in healthcare.
  • Be empathatic - Empathy might be the single most important skill for anyone working in healthcare. Practice by thinking "Today, I’m not a provider or administrator. Today, I’m the patient walking in these doors for the first time. What do I see? Riff on the idea, always challenging yourself to put yourself in the patient’s shoes. How would a patient use this service? What would a patient think of this cafeteria food?
  • Embrace extreme usecases - Identify the extreme users of your services and observe their behaviour and listen to their communications. What can you learn from them? Are your waiting room seats uncomfortable for the elderly? Do ePatients with smartphones portend the future for the entire next generation of patients? What processess would you develop or change based on the answers?
  • Engage designers - OXO didn’t re-invent the vegitable peeler on their own. They worked with SmartDesign. Healthcare providers can find local or nationally renound tallent. Sure, it comes at a cost, but think of a well designed offering as a compeitive advange. You’d pay a reasonable price for a consultant who could help you grow marketshare, right?

By the way, healthcare device manufacturers and supply vendors are no strangers to working with designers. IDEO and SmartDesign have both worked with vendors on items such as:

  • Cardinal Health Endura Scrubs

    Many hospital workers complain about the baggy, pajama-like, and unprofessional look of traditional ‘scrubs’. Furthermore, over 70% of hospital employees are women, yet they are forced to adapt to clothing that was designed for an XL-sized man. The Endura Performance Apparel Scrubs is a line of cost-effective high performance scrubs that we designed as true unisex wear with benefits for women and men alike. They are a vast improvement on their predecessors because of design innovations such as collars that don’t blouse open to over-expose females…

  • Ethicon Endo-Surgery Generator

    Equipment in the operating room environment can be complex and intimidating, prompting the need for intuitive technology solutions that help OR nurses focus more on patient care. The new EES Generator combines advanced technology, multifunctionality, and intuitive touch screen simplicity into one compact, easy-to-operate unit.

  • Lifeport Kidney Transport System

    The LifePort Kidney Transporter provides a new high-tech alternative to the conventional method of organ storage and transportation—a cooler filled with ice.

  • Finally, here’s IDEO’s Tim Brown at the 2009 TEDmed event on Designing Healthcare

Healthcare's digital divide: consumers vs providers

Last week, I wrote about embracing niche use cases, or what is known as the long tail. I referenced a William Gibson quote: The future is here…it’s just not evenly distributed.  If we are defining the future as processess, ideas, or technologies which sound far fetched to most, but in actuality exist in niche areas, then there is another way to consider their distribution. These processess, ideas or technologies can be widely accepted by some groups but still dismissed as "the future" by others. Consider mobile health technology.

According to the Pew American Life Project, nearly half of US adults have smart phones. Float Mobile Learning suggests there are 186 phones for every hospital bed in the US. They also suggest health apps is the 3rd fastest growing area on Apple's App Store. In 2011, South by South West, the popular interactive and music festival in Austin added a healthcare track. This year, the Health Track drew thousands, including big brand names like Qualcom, Cisco, and more.

But wait, there's more.

I created my own infographic... actually, it's part of a slide deck I use internally from which I've stripped the branding and strategy parts. Still, it shows how online and mobile health have tipped, and for consumers, are no longer niche areas.

See the trend here? If 80% of US Adults (including 56% of seniors) are going online for health information, can we really say the distribution is uneven?

The Digital Divide

There is a term, the digital divide which speaks to the rift between those with internet access and/or tech skills, and those without. Examples include the elderly and underserved communities, though there are certainly exceptions in those demographics.

There is another digital divide. When we consider the relatively wide adoption of online and mobile health ideas, processess and technologies, there is still a group for whom this is the's out of reach, or not part of the plan: provider organizations.

Here, the future is evenly distributed among the general population, but very sporadically adopted by providers.

I'm not pointing fingers. This isn't easy stuff. 80% of doctors may have smart phones, according to Float, but how many are also advanced programers and IT gurus? And should we expect them to be? Nor should we expect them to expend their precious margins - believe me, they aren't as high as pop culture would suggest - on developing a state-of-the-art application.

Nevertheless, I suggest there are ways for providers and health systems to start embracing the future:

  • Use what is already available - if you have an EMR with a patient portal, then encourage patients to upload data from health apps. Likely, it will start as CSV attachments which will not immediately be discrete data. Nevertheless, it is engaging for patients, helpful to providers and forward thinking.
  • Share your expertise online - 80% of US adults want health information online, be part of filling the vacuum. When I give talks to clinical folks this is the point I stress the most. There is a powerful difference between hearing your local doctor's reaction to a new study and reading a national, disembodied by line on a national news site. Be the local expert!
  • Partner - if the idea of building your own app, accepting patient data, or starting a youtube channel is daunting, find someone who can help. This is part of a consumer's decision making process, how savvy, available and with it is my doc or health system? Would you fly an airline that didn't let you book online or bank with a bank that didn't have online banking?
  • Embrace cost reduction - If you are a primary care provider, do you really want to ask people to wait in your waiting room for 40 minutes to see you for 10 to get a refill on allergy meds? Building a process for reimbursable eVisits isn't nearly as hard as it sounds. Patients want them. We can FaceTime or Skype around the world, but not our doctors? How's that for uneven distribution?
  • Self-scheduling - finally, in the no-brainer category, nearly all airline tickets are booked online. OpenTable dominates dinner reservations via the web and mobile app. Why does it take a 10 minute call to get a doctor's appointment at a horrible time on a day that doesn't work for me?
One thing is clear, if we consider the uneven distribution of mHealth in terms of consumer vs provider, the idea is already mainstream for a huge segment of the market. With prospects like that, it doesn't take much to find gold. Embracing online tools and mHealth is going to be a major differentiator for providers and health systems who get on the band wagon early.

Mobile Medicine & Mobile Health Care: Float Mobile Learning.


the future [of medicine] is already here

The future is's just not evenly distributed.  Or so goes the original quote from science fiction author William Gibson.

That's also the line the Alternative Futures group used in describe their futuristic model of primary care.

Challenges abound

We hear about the challenges facing healthcare from every angle; and it's not just those of us intrenched in the industry who are talking about them. Last week, the Washington Post's Ezra Klein published a story titled: Why an MRI Costs $1,080 in America and $280 in France.

 There is a simple reason health care in the United States costs more than it does anywhere else: The prices are higher. That may sound obvious. But it is, in fact, key to understanding one of the most pressing problems facing our economy. In 2009, Americans spent $7,960 per person on health care. Our neighbors in Canada spent $4,808. The Germans spent $4,218. The French, $3,978. If we had the per-person costs of any of those countries, America’s deficits would vanish. Workers would have much more money in their pockets. Our economy would grow more quickly, as our exports would be more competitive.

It is not all about high costs either. The American Medical Association predicts the US will have a shortage of over 91,000 physicians by 2020. JAMA illustrates the point by suggesting primary care doctors will need to double their patient panel size from 2,000 patients to 4,000.

But there is a plan, right?

There are no shortage of plans or experts to talk about them. CMS has announced initial payments to ACO pioneers will come this sparing. The Patient Centered Medical Home model is gaining popularity. Payors are also chiming in, at HIMMS conference, Aetna's CEO hinted at major changes to the commercial insurance industry:

Aetna CEO Mark Bertolini caused quite a stir when he said at a Las Vegas conference a few days ago that the insurance industry as we know it is, for all practical purposes, a dinosaur on the verge of extinction.


Bertolini ticked off a number of reasons why providing basic health insurance to Americans was no longer viable — changes in demographics and the economy and, of course, health care reform at both the state and federal levels. What he did not say was that the standard operating practices of the industry were simply not sustainable and actually contributed more to the demise of the business model than any external factors.

The future is here

In their white paper, Primary Care 2025: A Scenario Exploration, Alternative Futures explores four scenarios around primary care in the US. They lay out cases which range from status quo to, what the author's suggest, is a futuristic model.

I Am My Own Medical Home A different “surprisingly successful” future for primary care that bifurcates between advanced, effective, efficient,cost-competitive, integrated delivery systems and sophisticated and personalized self-care, supported by advanced knowledge technologies that allow people to take over many functions of primary care for themselves.


More important were the disruptive technologies that developed throughout the 2010s that put more and more control of health and health care into the hands of patients. New smartphone “apps” monitored a person’s diet, physical activity, and sleep patterns, and collected this data in personal health records (PHRs). New biomonitoring devices that measured blood pressure, blood chemistry, and even blood flow noise within the body could alert people to changes in their health. Lab tests conducted by the device at home, or sent by mail to a lab, provided a low-cost alternative to similar services previously provided in formal health care settings. Social networks, both in large population platforms like Facebook and Google, and in targeted networks like PatientsLikeMe, helped to formalize and extend the informal relationships that had always provided a large share of people’s health-related information.

These things aren't futuristic. They aren't imaginary, pie in the sky, would-be-nice-to-have things. They exist today. It's what Gibson means about the future being here, just not evenly distributed. Because these tools and their users, known as quant selfers, are not mainstream - or at least in the boardrooms of provider organizations, they are often discounted as fringe; unevenly distributed among the population of "normal patients."

Addressing the minority tastes

Chris Anderson, editor of Wired Magazine speaks about niche groups whose interests he calls minority tastes. The thing about niche interests, Anderson calls out, is we all have them. They are likely some of our favorite things - a fringe band, a campy TV show, a strange food. They are the unique things that make

Anderson has written about catering to minority tastes in The Long Tail. Graphically, if you were to measure the interest in a product or service, there has traditionally been a drop off point; a point when the market is saturated with users or the producer has hit their capacity to supply the thing. Anderson speaks about record sales. There was a point where a stores shelves could only hold so many CDs, so store owners had to chose which albums to carry. Once buyers had purchased the top selling albums, the curve dropped off.

In the digital age - we can all agree, that future is  here and evenly distributed, right? - these things have unlimited capacity. There is no feasible capacity limit for the number of tunes Apple can sell on iTunes or videos Netflix can deliver via streaming. So, there is no reason to limit the availability of the store's supply and there is no limit on the customer's interests.

Rather than dropping off, the distribution just spreads out over a larger range of a more shallow audience or smaller production.

Clear as mud?

In healthcare, we often wait for things to tip. For example, we need a market size to be substantially large enough to warrant building a new MRI center, otherwise, the curve dropps off too soon and we don't make enough to support it. There is also that ever-nagging fear of the unknown, or new things. Look at EMR adoption.

Those constraints don't apply for embracing virtualized care, quantified self models, and medical management. Why? Well, the future is here. We know people are using FitBits, the Zeo Sleep Manager, iPhone glucometers, and blood pressure cuffs. We don't have to wait for them to tip into a larger market segment.

How do we do it? Here are several lost cost, high impact ways:

  • Engage ePatients - ePatients are patients who actively seek to participate in medicine. Think about hosting an ePatient speaker for a board meeting or design session. ePatients are the ticket to understanding the long tail in healthcare. They have niche interests and are not evenly distributed, but they want access to data and electronic communication with providers and understand the value of holistic relationships as well as retail models. They represent the future, and they are here.
  • Embrace Quant Selfers - encourage those interested to upload data through an EMR patient portal. It doesn't require any effort, but it could provide a world of returns (on health)
  • Build online patient support communities - facilitate spaces for patients to engage with each other, and form support and knowledge groups.
  • Engage with patients online, on the sites they use, in a way that adds value. This cannot be overstated. Marketing messages via social media, while they may provide incremental volume, do very little to affect the health of your followers. The meaningful use of social media in healthcare starts with focusing on outcomes.
  • Share data - Publish data on case volumes and quality. Hey, CMS has made their claims set public, what do you have to lose?


Below, Chris Anderson speaks about the long tail:

Blue Ocean Strategy

There is a longstanding beliefe about how patients chose their healthcare providers and services. "[P]atients [are] passive health care consumers of physician services..." We go to a doctor a friend or someone at work tells us about, and if we need a specialist or study, we go where that doctor suggests. Is that the case because people want to be passive? Or is it because the "system" is structured in a way which makes consumer choice too difficult to contemplate?

Sometimes the universe gives you subtle hints, and sometimes it smacks you upside the head. Within the last four weeks, I've been inundated with references to Kim and Mauborgne's Blue Ocean. Blue Ocean is book and way of thinking about strategy.

When I first read Blue Ocean a few years ago, I didn't have a context for it and consequently didn't fully appreciate it.

Among other hints, we've been studying Blue Ocean in our graduate program which has given me a renewed interest. So, I'm re-reading it. Or rather, re-listening to the audio book on runs. Same difference.

The biggest lesson for me, to boil it down, is the need for any business to understand its market and its customers.

Understanding customers and markets isn't the same as asking them what they want. It's more about designing strategies, products, processess and services which addresses needs, even if they are unspoken, or even unknown.

Patients (and we're all patients aren't we?) would gladly chose their healthcare in a consumer directed world.

We've built a system around monolithic hospitals with radial arms touching pockets of outpatient care. Imagine if we reversed today's design. What if, instead of one huge epicenter, we had storefronts everywhere? Family medicine, internests, and other primary care practitioners, operating as a unified, front-line brand under consistant quality expectations which could be deployed around the service area as the face of the brand.

What if:

  • Care and experience were top priorities for providers (I'd be willing to be compassion is the biggest unmet, unspoken need)
  • Going to the doctor was as easy as going to Starbucks
  • Patients could schedule their own appointments, on mobile devices.
  • We could use FaceTime rather than waiting in waiting rooms.
  • Healthcare data belonged to patients, and providers would access it, with our permission, as they need it.
  • There would be navigators who's job would include making sure meds were picked up and appointments scheduled.
  • Docs would follow up about tests and treatment directly. And, they'd be accessible (within reason) by email or phone or twitter or text...

I know what you are thinking, many of these things are happening now. But not as a cohesive strategy for provider organizations. Providers are not thinking about designing strategies around emerging consumer wants. Why? The perception is the money is in the old school way of operating.

Remember when coffee used to come in a can from the grocery store? Did we think we wanted a coffee store on every corner? Starbucks tapped into that consumer desire and it seems to have worked out for them.

From the Blue Ocean site:

If the value and profit propositions are strong but the people proposition does not motivate the organization to move forward with focus and commitment, it will result in execution failure. Alternatively, if the people proposition is powerful but the value and profit propositions are weak, the company’s performance will be lackluster due to formulation failure.

via Blue Ocean Strategy.